Systemic failure to rule out potentially fatal pathology before discharge

1. This report discusses the services provided to Mr A by Health New Zealand|Te Whatu Ora (Health NZ) Southern. The complaint, made by Mr A’s son, Mr B, concerns the care provided by a gastroenterologist, Dr C, and a junior surgical registrar, Dr D. Mr A had had an abdominal aortic aneurysm (AAA) repair in September 2017, and he presented at the Emergency Department (ED) at a public hospital in 2019 with a suspected upper gastrointestinal (UGI) bleed.
2. While in the ED, Mr A was assessed by Dr D, on behalf of the vascular service. Dr D was working in Neurosurgery but covering other surgical specialties while on call overnight. With Mr A’s prior AAA repair, an aorto-enteric fistula (AEF) needed to be considered and ruled out. However, Dr D was unaware of this and documented that there was ‘no evidence of aortic pathology’.
3. Later that evening, Mr A’s care was transferred to the Gastroenterology Department. The gastroenterologist, Dr C, received a verbal handover and said that he was told that an AEF had been ruled out by the vascular service. Dr C accepted this advice.
4. Mr A remained in hospital for a few days to be monitored and underwent a gastroscopy, which found non-erosive gastritis. He was discharged home with an urgent referral for a colonoscopy. Sadly, the following day Mr A collapsed and died at home. The cause of death was determined to be hypovolaemic shock following severe acute gastrointestinal haemorrhage.
5. Although the cause of death was unrelated to an AEF and the post-mortem found no evidence of an AEF, this pathology is potentially fatal, and in Mr A’s case should have been considered and ruled out. This report highlights the importance of ensuring that junior staff are well supported and equipped to perform their allocated role, and that hospital systems and culture ensure that there is effective communication, ownership, and critical thinking amongst staff.

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